Contingency Management
Motivational Incentives:
Past, Present and Future
Maxine Stitzer, Ph.D.
Johns Hopkins University SOM
NIDA/CTN
Regional Dissemination Conference
Baltimore, MD
June 3, 2010
What you will hear today
• CM/Incentives Background
– Development and efficacy research
• Effectiveness testing
– National Drug Abuse Clinical Trials Network
• Implications for future
– Pathway for adoption by treatment providers
Drug User’s Dilemma
Easy money
Hang with friends
Get high
Get a job
Time with family
Better health
Motivational Incentives Can
Counteract Ambivalence
Make sober living a more
attractive option through
positive reinforcement of
abstinence and other
behavior change
People Respond to Consequences
• Behavior can be changed by consequences
– Rewards increase desired behavior
– Punishment and sanctions decrease undesired
behavior
Contingency Management:
Application in Drug Abuse
• Measurable target behavior
• Rewarding consequence
Application in Drug Abuse
Treatment: Early Studies
• Behavioral targets:
– Counseling attendance
– Drug use during treatment
– On-time fee payment
• Reinforcing consequences:
– Money (or vouchers)
– Privileges (e.g. methadone take-home doses)
Incentive Effects on
Benzodiazepine Use
3-month intervention with methadone maintained
benzo users; incentive is take-home or money
Percent benzo negative urines
– Before incentives
– During incentives
– After incentives
Stitzer et al., 1982
9%
53%
11%
Voucher Reinforcement
making cocaine abstinence a more
attractive option
• Intensive counseling plus
• Points earned for cocaine negative
urine results
– Escalating schedule with reset penalty
– Trade in points for goods
– $1000 available in first 3 months
Steve Higgins
Voucher Incentives in Outpatient
Drug-free Treatment
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
Voucher Incentives in Cocaine Abusing
Methadone Patients
100
Silverman et al., 1996
Vouchers
80
Percent Cocaine Negative
Control
60
*
*
*
*
*
*
*
*
40
20
0
1
2
3
Baseline
4
5
2
4
6
Intervention Weeks
8
10
12
Voucher Reinforcement
• Elegantly incorporates behavioral principles
designed to initiate & sustain abstinence
• Demonstrated efficacy in controlled trials
BUT
• Sample sizes are small
• Costs were high ($1000 per client could be earned)
$1000???
You’ve got to be
kidding!!!
Nancy Petry’s Fishbowl:
Intermittent Reinforcement Schedule
QuickTim e™ and a
Pho to - JPEG de co m press or
are n eed ed to se e this p ictu re .
For cost reduction in community clinic settings
Fishbowl Method
Incentive = draws from a bowl
- Draws earned for each negative urine or BAC
- Number of draws can escalate
- Bonus draws can be given for
consecutive weeks of abstinence
Half the slips are winners
Win frequency inversely related to cost
 largest chance of winning a
small $1 prize
 moderate chance of winning
a large $20 prize
 small chance of winning a
jumbo $100 prize
Retention:
Alcoholics in Outpatient Psychosocial Treatment
Petry et al., 2000
Percent positive for any illicit drug
50
STD
CM
40
30
%
20
10
0
Intake
Week 4
Week 8
Petry et al., 2000
Efficacy of abstinence reinforcement
demonstrated
Drug-free and methadone
treatment populations
Voucher and prize draw methods
Generality of Abstinence Reinforcement
Effects Across Abused Substances
Cocaine
(Higgins et al., 1994; Silverman et al., 1996, 2004; Petry & Martin, 2002)
Alcohol
(Petry et al., 2000)
Opioids
(Bickel et al., 1997; Silverman et al., 1996)
Marijuana
(Budney et al., 1991, 2000, 2006)
Nicotine (Tobacco smoking)
(Stitzer & Bigelow, 1984; Roll et al., 1996; Shoptaw et al., 2002)
National Drug Abuse Treatment
Clinical Trials Network
Bridging the gap between
research and practice
Clinicians
Researchers
CTN Mission
• Conduct effectiveness research with
community treatment partners
– Do interventions developed and studied in research
clinics work when tested in the real world settings?
– If so, how can we make these new treatments part
of usual care?
How do abstinence incentives fit into the
clinical picture?
• Add-on to counseling as usual
– Special intervention to enhance motivation for
sustained abstinence
– Focuses on the positive to recognize and celebrate
success
– Allows counselors to work on life-style changes
that can sustain abstinence beyond incentives
CTN MIEDAR Study
Participants = 800 stimulant users
(cocaine or methamphetamine)
Conducted in:
6 methadone and
8 drug-free programs
Random Assignment
• Usual care
• Usual care enhanced with
abstinence incentives
• 3-month evaluation
Sample Collection
Twice Weekly
Intermittent Reinforcement Schedule:
Draws from the Abstinence Bowl
Good
Job
Small
Small
Large
Small
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Small
Good
Job
Draws Escalate with
Stimulant- and Alcohol-Free Test Results
5
4
3
2
1
Weeks Drug Free
# Draws
Bonus Draws for
Opiate and Marijuana Abstinence
2
2
2
Weeks Drug Free
2
2
# Draws
Half the chips are winners
Examples of Prizes
42%
SMALL
($1-$5 items)
8%
LARGE
($20 items)
JUMBO
($80-$100 items)
Total Earnings
• $400 in prizes could be earned on average
– If participant tested negative for all targeted
drugs over 12 consecutive weeks
MIEDAR: Who participated and
how did it turn out?
PATICIPANT DEMOGRAPHICS
METH
(N=388)
FEMALE (%)
MINORITY (%)
AGE (mean yrs)
EDUC (mean yrs)
EMPLOYED (%)
PROB/PAROLE (%)
METH DOSE(mg)
TIME IN TX (mos)
45
49
42
12
32
16
86
9
PSYCH
(N=415)
55
58
36
12
35
36
--1
METHADONE PROGRAM
STUDY RESULTS
Study Retention in Methadone Treatment
Percentage Retained
100
80
60
Incentive
Control
40
20
0
RH = 1.1
CI = 0.8,1.6
2
4
6
8
10
12
Percentage of stimulant negative
urine samples
Percent Stimulant Negative Urines
100
Abstinence Incentive
Usual Care
80
60
40
20
OR=1.91 (1.4-2.6)
0
1
3
5
7
9
11 13
15 17 19 21 23
Study Visit
Individual Subject Performance
21% Incentive
vs
8% control
had prolonged abstinence outcome
(19-24 Stimulant Negative Urines)
Outpatient Psychosocial Clinics:
Contrasting Outcomes
Percent Stimulant Negative Urines
Percentage of stimulant negative
urine samples
100
80
60
40
Abstinence Incentive
Usual Care
20
0
1
3
5
7
9
11 13 15 17 19 21 23
Study Visit
Incentives Improve Retention in Counseling Treatment
100
Incentive
Control
Percentage Retained
80
60
50%
40
35%
20
0
RH = 1.6 CI=1.2,2.0
2
4
6
8
Study Week
10
12
Psychosocial Site Differences:
Raising Performance
• Abstinence incentives worked best in clinics
with lower retention
– Control mean = 3.6 - 6.8 weeks
• Clinics where clients were usually retained for
8 weeks didn’t show improved retention with
incentives
Individual Subject Performance
19% incentive vs 5% control
had 12 weeks of
stimulant negative samples
RESEARCH CONCLUSIONS
Incentives can improve client
outcomes on retention and
drug use when implemented
in community treatment
programs
Dissemination/Adoption
• Clearly recognized as one evidence-based practice
advocated by program funders and licensers
• 1/4 - 1/3 of clinics are currently using incentivesmostly to reinforce attendance (Roman et al., 2010)
• Information on what it is and how to do it
increasingly available
– e.g. PAMI materials at www.nattc.org
– programs such as this one today
Should Kids Be Bribed To Do Well
In School?
TIME
MAGAZINE
April 8, 2010
Why Adopt Motivational Incentives?
from Kellogg et al., Something of Value, JSAT, 2005
Counselors Come to Understand
Reinforcement
• “We came to see that we need to reward people
where rewards in their lives were few and far
between
• We use the rewards as a clinical tool – not as
bribery, but for recognition
• The really profound rewards will come later”
49
Clients Like it
• “Clients are proud and are having fun
• Early in treatment, when their name is called out,
they are feeling good that they are being
acknowledged
• For once in their life, they are being rewarded for
something”
50
Contributes to Positive
Clinician-Client Interaction
• When patients publicly, and sometimes
tearfully, acknowledged the counselor’s help
in public, the staff felt a sense of gratitude
• “In the last two award ceremonies, clients said,
‘I want to thank the staff….’ That sounded
real good – we felt appreciated”
51
Looking Into the Future
Peace, Prosperity and…
Prizes in every clinic!
Motivational Incentive
Workshops
Incentive Approaches for Clinicians
Fo u rt h V isi t S eco nd V is it
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Da te:
Da te:
T a sk :
3 N e gat ive
UA s
T h ird V isi t
Da te:
T a sk :
F ir st
V isit
Pro b at io n
O ff ic eV isi t
Da te:
Christine Higgins
Dissemination Specialist
CTN Mid Atlantic Node
T a sk :
T a sk :
N e gat ive U A
N e gat ive U A
14 D ay
A n n iv er sa r y !
Incentive Contracting for Adolescents
Ashli Sheidow, Ph.D.
Associate Professor Psychiatry
Family Services Research Ctr
Medical Univ South Carolina
Incentive Implementation for Administrators
Salon A
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Jim Beiting
Executive Director
Community Behavioral Health
Hamilton, Ohio